F0695

D

Failure to Follow CPAP Manufacturer Guidelines for Oxygen Use

Rexburg, Idaho Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide respiratory services in accordance with CPAP manufacturer warning guidelines and professional standards of practice for one resident whose respiratory equipment was observed. The CPAP manufacturer’s warnings specified that oxygen supports combustion and should not be used while smoking or near open flame, that when using supplemental oxygen with the CPAP the device must be turned on before the oxygen is turned on and the oxygen must be turned off before the device is turned off to prevent oxygen accumulation in the device, and that a specific pressure valve must be placed in-line between the device and the oxygen source to prevent backflow of oxygen into the device when it is off. The manufacturer’s explanation stated that if oxygen flow is left on while the device is not operating, oxygen may accumulate within the device enclosure, creating a risk of fire, and that failure to use the pressure valve could result in a fire hazard.

The resident involved had multiple diagnoses, including a left femur fracture and chronic respiratory failure with hypoxia. On observation in the resident’s room, the CPAP machine was turned off while supplemental oxygen at 2 L/min was still turned on and being bled into the CPAP device, contrary to the manufacturer’s instructions. A subsequent observation with the Administrator confirmed that the resident’s supplemental oxygen continued to be bled into the CPAP while the CPAP was not turned on, and that the required Respironics pressure valve was not installed in the circuit between the device and the oxygen source. The Administrator stated that the oxygen in the resident’s room should have been shut off when the CPAP was turned off and was not.